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Prolonged Intraoperative Cardiac Arrest in a Young Patient with Successful Precordial Thump

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Prolonged Intraoperative Cardiac Arrest in a Young Patient with Successful Precordial Thump Prolonged Intraoperative Cardiac Arrest in a Young Patient with Successful Precordial Thump Authors: Sitelnissa Saeed Ahmed,1 *Gamal Abdalla Mohamed Ejaimi,2 Areeg Izzeldin Ahmed Yousif3 1. Intensive Care, Aseer Central Hospital, Abha, Saudi Arabia 2. Department of Anesthesia and Intensive Care, Sabah Al-Salem, Kuwait 3. Department of Anesthesia and Intensive Care, Ahmed Gasim Hospital Heart Surgery and Kidney Transplant Center, Khartoum North, Sudan *Correspondence to [email protected] Disclosure: The authors have declared no conflicts of interest. Received: 02.02.20 Accepted: 30.03.20 Keywords: Anaesthesia, cardiac arrest, cardiopulmonary resuscitation (CPR), intraoperative, postresuscitation care, pulmonary embolism (PE). Citation: EMJ. 2020;DOI/10.33590/emj/20-00024. Abstract Cardiac arrest during surgery is rare but is one of the most dreaded complications. Precordial thump (PT) had been used for a long time, but in the present day it has become obsolete. In regard to the witnessed onset of asystole, there is insufficient evidence to recommend for or against the use of the PT. This case report is of a 17-year-old male who presented to hospital with a congenital haemangioma on the right calf. He had no other significant medical conditions and was on no other medications. The patient history, clinical examination, and investigations were normal. He had undergone an operation 3 weeks previously where a section of his haemangioma was excised, and an appointment was made for excision of the remaining haemangioma. Anaesthesia induction and endotracheal intubation were smooth and uneventful. Following lifting and exsanguination of the patient’s leg by Esmarch bandage, he developed ventricular fibrillation and arrested with asystole. Cardiopulmonary resuscitation was performed, with no good response, for approximately 50 minutes. Lastly, a PT was performed, and the patient’s heart rate immediately returned. The operation was postponed. Postresuscitation care was conducted in an intensive care unit. The patient was later discharged without complications. INTRODUCTION operating room. Anaesthesia-attributable cardiac arrests are related to airway Cardiac arrest during surgery is rare but is one management and medication administration, of the most dreaded complications, particularly which are important considerations in prevention 2,3 when there is no obvious underlying cause or strategies. Post-cardiac arrest care using a high- risk. Some studies conducted between 2001 quality integrated multisystem of support and and 2012 quoted the incidence of intraoperative management could significantly affect patient cardiac arrest (ICA) to be 1.10–7.22 per 10,000 outcome. Post-cardiac arrest care should be surgeries.1-4 Cardiac arrests related to anaesthesia implemented according to the 2015 American are classified as avoidable but are thought Heart Association Guidelines Update for to have a higher survival rate compared to Cardiopulmonary Resuscitation and Emergency other possible causes of cardiac arrest in the Cardiovascular Care (AHA CPR ECC).5 CARDIOLOGY • September 2020 EMJ A 17-year-old male presented to the hospital immediately returned. With a firmly clenched with a congenital haemangioma on the right right fist, at approximately 20 cm above the calf, measuring approximately 9x10 cm. His body patient, a strike was given on the inferior third weight was 60 kg. The patient had no other of the patient sternum. The ECG showed a complaints and no relevant medical history. narrow QRS complex tachycardia which then He had a heart rate of 80/minute, respiratory changed to a sinus rhythm. The end-tidal CO2 rate of 17/minute, blood pressure of 120/70, on the capnograph was raised immediately. The operation was postponed. The patient was and oxygen saturation (SpO2) of 98%. Clinical examination of the cardiovascular, respiratory, stabilised and transferred to an intensive and nervous systems was normal. He had care unit (ICU). Monitoring was continued, undergone an operation 3 weeks previously and an arterial line was inserted for invasive where a section of his haemangioma was excised, blood pressure and repeated arterial blood and an appointment was made for excision of gases sampling. Synchronised intermittent the remaining haemangioma. The investigations, mechanical ventilation mode was used. including complete blood count, random blood Four hours later, the patient recovered his sugar, liver function test, urea, creatinine, and spontaneous respiration and his level of electrolytes, were all within normal limits. The consciousness began to improve. Two hours after patient fasted for 8 hours prior to the operation, this he was extubated safely. as per hospital protocol, with intravenous fluids A pulmonary embolism (PE) that migrated from maintenance. The patient was connected to the location of the previous surgery was thought standard monitoring as per the American Society to be the most likely diagnosis. He was kept in of Anesthesiologists (ASA) guidelines.6 After the ICU on 5,000 U heparin intravenous bolus, preoxygenation with 100% O , anaesthesia was 2 followed by a continuous infusion of 1,200 U/hour induced with 100 µg fentanyl, 130 mg propofol, until the following day. On Day 2, he was discharged and 35 mg rocuronium. The tracheal intubation to the intermediate care unit where he stayed for was performed uneventfully. Anaesthesia was 2 days. The cardiology, haematology, respiratory, maintained with 50% O in N O, with an isoflurane 2 2 and neurology evaluations, examinations, and minimum anaesthetic concentration of 1.6%. All investigations were completed and revealed patient and ventilator parameters were normal. no abnormality, apart from a small thrombus The patient’s leg was lifted by the surgeon when at the site of previous surgery, identified by a applying the Esmarch bandage. Immediately doppler ultrasound. following exsanguinations and compression over both the calf and the site of the previous operation, the patient developed ventricular DISCUSSION fibrillation (VF) and became hypotensive and arrested in asystole. Effective cardiopulmonary Intraoperative blood loss, as indicated by the resuscitation (CPR) was started with 100% volume of transfusion, was the most important fraction of inspired oxygen, bag valve mask predictor of ICA. ASA status and functional 1-4 ventilation, and cardiac compressions. Checking status were other important risk factors. of the equipment, machines, and breathing Cardiac arrests entirely related to anaesthesia system, as well as verification of the endotracheal are classified as avoidable and are thought to tube, were completed with no defects reported. have a higher survival rate compared to other Hypoglycaemia was ruled out. Adrenaline was possible causes of cardiac arrest in the operating 3 given intravenously at 1 mg every 3–5 minutes, up room. The study by Braz et al. concluded that to a total dose of 10 mg. Intravenous 300 and 150 all anaesthesia-attributable cardiac arrests were mg amiodarone were administered. There was no related to airway management and medication good response for approximately 50 minutes. administration, which are both important considerations in prevention strategies.2,3 The reversible causes of cardiac arrest ('four Hs During surgery, the context of positioning and and four Ts') were checked simultaneously specific procedures may have a particular effect alongside the ongoing effective CPR. Lastly, on cardiac arrest. However, a proper a precordial thump (PT) was delivered by a understanding of the mechanisms and senior anaesthetist, and the patient’s heart rate management options related to these events Creative Commons Attribution-Non Commercial 4.0 September 2020 • CARDIOLOGY would certainly assist in minimising adverse for VF, but is used in cases in which there is outcomes.7 The outcome of cardiac arrest no defibrillator available. It is not effective during anaesthesia is generally good, with most in terminating VF and may cause rhythm patients leaving the hospital alive and seemingly deterioration. For witnessed onset of asystole, well. A complete systematic assessment of there is insufficient evidence to recommend the patient, equipment, and drugs should be for or against the use of the PT.11,12 Few studies completed during an ICA, even if the cause of have described the value of PT as first-line the cardiac arrest is already hypothesised.8 treatment to monitored out-of-hospital cardiac Cardiac arrests during nonregular working arrest as a result of VF and pulseless ventricular hours tend to have worse outcomes, which may tachycardia.13 A study by Madias et al.14 indicate that the availability of human resources recommended PT for asystole.14 A serial PT was influences survival.4 successfully used in a 28-day-old newborn baby who presented with a refractory supraventricular Deep venous thrombosis, in most reported tachycardia and cardiovascular collapse after cases, involves the lower extremities. PE can amiodarone administration.15 Post-cardiac arrest occur in young patients with unknown risk care using a high-quality integrated multisystem factors and be without anticipation. Schonauer of support and management could significantly 9 et al. reported a large PE in a 23-year-old affect patient outcome. Post-cardiac arrest woman following bilateral breast augmentation. should be implemented following the 2015 The authors recommended more restrictive risk AHA CPR ECC.5 In the patients undergoing assessment scores, such as the Caprini score, valve
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